[Surgical Case of Bronchial Mucoepidermoid Carcinoma Safely Diagnosed by Enucleation Under the Bronchoscopy After Bronchial Arterial Embolization].

A 28-year-old male presented to our hospital with hemoptysis and his chest computerized tomography (CT) showed the right middle and lower lobe atelectasis due to the tumor of right intermediate bronchial trunk. To reduce the blood flow to the tumor, bronchial arterial embolization was performed and the tumor was resected using Cryoprobe with a flexible endobronchial scope. Thus, we could observe the tumor localization and diagnose before the surgical procedure. We performed the right sleeve middle lobectomy and the right lower lobe was safely preserved.

Risk factors of incisional hernia at the umbilical specimen extraction site in patients with laparoscopic colorectal cancer surgery.

Purpose: Incisional hernia (IH) is a frequent complication following laparoscopic colorectal surgery. The present study investigated the risk factors for IH after laparoscopic surgery for colorectal cancer. Methods: A retrospective study was conducted on 202 patients who underwent laparoscopic surgery for colorectal cancer. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with IH. Results: The overall incidence of IH was 25.7% (52 of 202). The univariate analysis showed that female sex (P=0.004), a high body mass index (P<0.001), non-current smoking habit (P=0.043), low level of hemoglobin (P=0.035), high subcutaneous fat area (P<0.001), high visceral fat area (P=0.006), low skeletal muscle area (P=0.001), long distance between the inner edges of the rectus abdominis muscle (P=0.001), long protrusion of the peritoneum at the umbilical site (P<0.001), and lymph node metastasis (P=0.007) were significantly more frequent in the group with IH than in the group without it. The multivariate logistic regression analysis revealed an older age (10-year increments: odds ratio [OR], 1.576; 95% confidence interval [CI], 1.027-2.419; P=0.037), lymph node metastasis (OR, 2.384; 95% CI, 1.132-5.018; P=0.022) and lengthy protrusion of the peritoneum at the umbilical site (10-mm increments: OR, 5.555; 95% CI, 3.058-10.091; P<0.001) were independent risk factors for IH. Conclusion: Our findings suggest that older age, lymph node metastasis, and lengthy protrusion of the peritoneum at the umbilical site are risk factors for IH after laparoscopic surgery for colorectal cancer. An assessment using these factors before the operation and the implementation of countermeasures might help prevent IH.

Time-Enhancement Curve of Four-Dimensional Computed Tomography Predicts Aneurysm Enlargement with Type-II Endoleak after Endovascular Aneurysm Repair.

OBJECTIVE: We investigated the hemodynamic features of Type-II endoleaks after endovascular aneurysm repair (EVAR) using four-dimensional (4D) computed tomography (CT) to identify patients with aneurysm enlargement. METHODS: During a 13-month period (January 2017-January 2018) at our institution, we performed 4D-CT examinations in 13 patients after EVAR because of suspected Type-II endoleaks. Three patients were excluded from the study because of other endoleaks or absence of detectable endoleaks. The ramaining 10 patients were divided into two groups: enlargement group (n = 4), in which the aneurysm volume increased, and stable group (n = 6), in which the aneurysm remained stable or shrank. A CT scanner and three-dimensional workstation were used. All images were obtained using a consistent protocol (22 phase scans using the test bolus tracking method). We analyzed the hemodynamics of the endoleak cavity (EC) relative to those of the aorta and evaluated the time-enhancement curves (TECs) using measurement protocols. The strengths of correlations between these factors in the two groups were analyzed statistically. RESULTS: TECs in the enlargement group showed a more gradual curve, and the upslope, the gradient of TEC in the ascending phase and the upslope index were significantly more gradual than those in the stable group (p = 0.0247, 0.0243). The EC washout and the EC washout index were also more gradual than in the stable group's (p = 0.019, 0.019). The enhancement duration was longer in the former than in the latter (80%, p = 0.0195; 70%, p = 0.0159; 60%, p = 0.0159). The CT number in the equilibrium phase was larger in the enlargement group than in the stable group (p = 0.019). CONCLUSION: The 4D-CT is useful for predicting aneurysm enlargement with Type-II endoleaks after EVAR.

A long-term survivor of undifferentiated carcinoma of the liver successfully treated with surgical treatments: A case report and literature review.

INTRODUCTION: Undifferentiated carcinoma of the liver is extremely rare. The biological characteristics and standard strategy for its treatment have not been established yet. PRESENTATION OF CASE: A 45-year-old man was admitted because of fever elevation and shivering. Abdominal computed tomography revealed a hypovascular cystic mass in segments 6 and 7 of the liver measuring 11.5 × 9.0 cm with ring enhancement and partial solid component. A diagnosis of liver abscess was made, and percutaneous transhepatic abscess drainage was performed. Reddish brown-colored pus showed no bacteria or amoebas. However, cytology demonstrated malignant cells. After additional examinations of magnetic resonance imaging and the positron emission tomography, extended posterior sectionectomy with cholecystectomy was performed. The excised specimen showed a solid and irregular tumor with extensive central necrosis. A pathological examination revealed diffuse proliferation of oval- and spindle-shaped malignant cells. Immunohistochemically, the malignant cells were diffusely positive for AE1/AE3 and vimentin and focally positive for granulocyte colony-stimulating factor and cytokeratin 19; however, hepatocyte-specific antigen, glypican 3, cytokeratin 7, and CD56 were negative. Therefore, a diagnosis of undifferentiated carcinoma of the liver was made. He has remained well without any recurrence for three years since the operation. DISCUSSION: Undifferentiated carcinoma of the liver might grow rapidly, resulting in necrosis with a cystic component. Therefore, it can be difficult to distinguish from liver abscess. CONCLUSION: This disease has markedly different clinical and biological features from common primary malignant tumor of the liver. However, if the tumor is a solitary mass, surgical resection might lead to a good prognosis.

Malignant lymphoma incidentally diagnosed due to the perforation of the small intestine caused by a fish bone: A case report.

INTRODUCTION: The ingestion of a foreign body is relatively common. However, it rarely results in the perforation of gastrointestinal tract. We herein report an unusual case of malignant lymphoma incidentally diagnosed after the perforation of the small intestine by a fish bone. PRESENTATION OF CASE: A 90-year-old woman was admitted to our hospital because of abdominal pain and vomiting. Abdominal computed tomography demonstrated free air and ascites in the abdominal cavity. In the pelvic cavity, a radiopaque linear shadow about 35mm in diameter was shown in the small intestine, and the stricture was exposed to the abdominal cavity. Therefore, a diagnosis of perforation of the small intestine due to ingestion of a foreign body and panperitonitis was made. Emergent laparotomy was performed. The intraoperative findings revealed perforation of the small intestine with a fish bone in the jejunum. Local inflammation at the perforation site was seen, and circulated wall thickness was observed at the distal side of the jejunum. Partial resection of the jejunum and anastomosis of jejuno-jejunostomy was performed. A pathological examination and immunohistochemical study of the resected specimen resulted in a diagnosis of malignant lymphoma of follicular lymphoma Grade 1. DISCUSSION: It is very difficult to identify the existence malignancy accompanied with gastrointestinal perforation with ingestion of a foreign body. CONCLUSION: In cases suspected of involving malignancy, careful observation during surgery is needed in order to avoid missing the accompanying malignancy.

Magnetic Resonance (MR) Imaging Assessment for Glossopharyngeal Neuralgia: Value of Three-Dimensional T2-Reversed MR Imaging (3D-T2R) in Conjunction with Other Modes of 3D MR Imaging.

BACKGROUND: To retrospectively examine the usefulness of gray-scale reversal imaging of T2-weighted images (3D-T2R) in conjunction with other modes of 3D MRI for preoperative assessments in patients with glossopharyngeal neuralgia (GPN) due to neurovascular compression. MATERIAL/METHODS: Imaging findings on 3D-T2R, constructive interference in steady state (CISS), and MRA were analyzed with reference to operative charts in 10 patients with GPN. RESULTS: Offending vessels were associated with the posterior inferior cerebellar artery (PICA) in 9 of 10 patients (90%). Eight of the 10 patients (80%) had offending vessels located at the supraolivary fossette. Of those eight patients, six (75%) had a shift of the ipsilateral vertebral artery to the affected side. Five (42%) and seven (48%) contact points were associated with the root entry/exit zone and the peripheral nerve system segment, respectively. In six of nine contact points (67%), 3D-T2R demonstrated the pathomorphological features at the contact points better than CISS. CONCLUSIONS: The offending vessels were mostly associated with posterior inferior cerebellar arteries, were frequently located at the supraolivary fossette, and had attachments at the root entry/exit zone and at the peripheral segment of the glossopharyngeal nerve, which was well demonstrated on 3D-T2R.

Arterial Spin-labeling in Central Nervous System Infection.

PURPOSE: To investigate the characteristics of arterial spin-labeling magnetic resonance imaging (ASL-MRI) in central nervous system (CNS) infection. METHODS: Thirty-two patients with CNS infections underwent a pulsed ASL-MRI. The findings on ASL-MRI were retrospectively assessed for the pathogens as well as each of the following four pathology classified based on conventional MRI findings: non-purulent parenchymal involvement, meningeal involvement, abscess formation, and ventricular involvement. RESULTS: Among the 17 patients with non-purulent parenchymal involvement, ASL-MRI revealed high perfusion in 8 patients (47%) and low perfusion 1 patient (6%). Especially, four of five patients (80%) with definite or suspected herpes simplex virus (HSV) infection showed high perfusion on ASL-MRI. Seventeen of 22 patients (77%) with meningeal involvement showed high perfusion along the cerebral sulci irrespective of the pathogens. Meanwhile, 4 of 16 lesions (25%) with abscess formation showed low perfusion and one of six patients (17%) with ventricular involvement had high perfusion. CONCLUSIONS: The characteristics of ASL-MRI in CNS infections were clearly delineated. ASL-MRI could be helpful for monitoring the brain function in CNS infections noninvasively.

Granulomatous reaction in hepatic inflammatory angiomyolipoma after chemoembolization and spontaneous rupture.

A 77-year-old Japanese woman was transported to a nearby hospital due to sudden abdominal pain and transient loss of consciousness. Abdominal computed tomography (CT) suggested hemoperitoneum and hepatic nodule. She was conservatively treated. Contrast-enhanced CT two months later revealed an increased mass size, and the enhancement pattern suggested the possibility of hepatocellular carcinoma (HCC). Under a clinical diagnosis of HCC, transcatheter arterial chemoembolization (TACE) was performed. A subsequent imaging study revealed that most of the lipiodol used for the embolization was washed out. Therefore, surgical resection was performed. Histologically, the nodule contained numerous inflammatory cells including small lymphocytes, plasma cells and macrophages. Notably, epithelioid granulomatous features with multinucleated giant cells were observed in both the nodule and background liver. Some of the multinucleated giant cells contained oil lipid. Among the infiltrating inflammatory cells, spindle-shaped, histiocytoid or myoid tumor cells with eosinophilic cytoplasm were found. The tumor cells were positive for Melan A and HMB45. The nodule contained many IgG4-positive plasma cells; these were counted and found to number 72.6 cells/HPF (range: 61-80). The calculated IgG4:IgG ratio was 33.2%. The nodule was finally diagnosed as previously ruptured inflammatory angiomyolipoma modified by granulomatous reaction after TACE.

Arterial spin-labeling MR imaging of cerebral hemorrhages.

INTRODUCTION: The purpose of this study is to identify the characteristics of brain perfusion measured by arterial spin-labeling magnetic resonance imaging (ASL-MRI) in cerebral hemorrhages. METHODS: Brain blood flow values (CBF-ASL values) for cerebral and cerebellar hemispheres and segmented cerebral regions were measured by ASL-MRI in 19 putaminal hemorrhage patients and 20 thalamic hemorrhage patients in acute or subacute stages. We assessed the lateralities of CBF-ASL values and the relationships between CBF-ASL values and other imaging findings and clinical manifestations. RESULTS: Both the 19 putaminal hemorrhage patients and the 20 thalamic hemorrhage patients had significantly low CBF-ASL values of the contralateral cerebellum in subacute stage, suggesting that ASL-MRI might delineate crossed cerebellar diaschisis (CCD). Ipsilateral low CBF-ASL values were observed in frontal lobes and thalami with a putaminal hemorrhage and lentiform nuclei, temporal lobes, and parietal lobes with a thalamic hemorrhage, suggesting that ASL-MRI showed the ipsilateral cerebral diaschisis (ICD). In the putaminal hemorrhage patients, the hematoma volume negatively affected both the bilateral cerebellar and cerebral hemispheric CBF-ASL values. In the thalamic hemorrhage patients, a concomitant intraventricular hemorrhage caused low cerebral hemispheric CBF-ASL values. CONCLUSION: The use of ASL-MRI is sensitive to the perfusion abnormalities and could thus be helpful to estimate functional abnormalities in cerebral hemorrhage patients.

Noninvasive method for mapping CVR in moyamoya disease using ASL-MRI.

PURPOSE: To project a noninvasive method for mapping cerebrovascular reserve (CVR) in moyamoya disease (MMD) using ASL-MRI. METHODS: 16 MMD patients underwent cerebral blood flow (CBF) examinations by standard ASL-MRI, pulse-wave-synchronized ASL-MRI (pulsy ASL-MRI) which tagged the arterial blood coincident with a peak of a pulse wave, and single photon emission computed tomography (SPECT) imagings with iodine-123-N-isopropyl-p-iodoamphetamine in the resting (rest-IMP) and after acetazolamide challenge (ACZ-IMP). Hemispheric 32-sided cerebral blood flow (CBF) values were measured with normalized CBF maps created from standard ASL-MRI (standard-ASL value), pulsy ASL-MRI (pulsy-ASL value), rest-IMP (rest-IMP value), and ACZ-IMP (ACZ-IMP value). CVR based on rest-IMP and ACZ-IMP values (IMP-CVR) was calculated. ASL-CVR was also calculated on the basis of corrected standard-ASL values and pulsy-ASL values, which were adjusted to the ACZ-IMP values and rest-IMP values, respectively, by the least-squares method. We assessed the relationships between rest-IMP values and pulsy-ASL values, ACZ-IMP values and standard-ASL values, and IMP-CVR and ASL-CVR. RESULTS: Significant relationships were observed between rest-IMP values and pulsy-ASL values (correlation coefficient (r=0.557, p<0.01)), ACZ-IMP values and standard-ASL values (r=0.825, p<0.01), and IMP-CVR and ASL-CVR (r=0.736, p<0.01). CONCLUSIONS: ASL-MRI is equivalent to SPECT and that it might serve as a noninvasive method for mapping CVR in MMD.

A technical perspective for understanding quantitative arterial spin-labeling MR imaging using Q2TIPS.

We illustrate the fundamental theoretical principles of arterial spin-labeling (ASL) magnetic resonance imaging (MRI) and show a system that employs the second version of quantitative imaging of perfusion using a single subtraction (Q2TIPS) to quantify cerebral blood flow (CBF). We also discuss the effects of the parameters used in Q2TIPS on CBF values as measured with ASL-MRI.

CT-gastrography for early gastric cancer visualized by wall-carving technique using contrast-enhanced MDCT for portal phase.

OBJECTIVE: The wall-carving (WC) imaging technique is used to evaluate early gastric cancer using multidetector row computed tomography (MDCT) image data for only the arterial phase. Our purpose was to investigate if WC images derived from portal phase MDCT images can enhance the visualization of early gastric cancer. SUBJECTS AND METHODS: Fourteen consecutive patients (average age/age range (years) = 75.8/61 to 86; male/female = 9/5) were enrolled. They were diagnosed with early gastric cancer and underwent contrast-enhanced MDCT before treatment. WC images of the arterial and portal phases were created from images scanned by 64-detector-row MDCT 40 and 60 seconds after the initiation of the contrast material injection, respectively. The correlation between the detection rates of lesions in the WC images and pathological findings was investigated. RESULTS: Totals of 71.4% (10/14) of arterial phase WC images and 71.4% (10/14) of portal phase WC images showed lesions. The imaging ability improved to 85.7% (12/14) when the two sets of images were combined. Well-differentiated adenocarcinomas tended to be visualized better in WC images of any phases. CONCLUSION: WC is an excellent image analysis technique for visualizing early gastric cancer lesions. The depiction rates were improved by using a combination of arterial and portal WC images. The scan timing after the contrast material injection should be carefully investigated to improve the detection rate of lesions.

Primary squamous cell carcinoma of the liver concomitant with primary colon cancer: report of a case.

A 55-year-old Japanese female was admitted to our hospital to treat colon cancer. Computed tomography revealed a 2.6 × 2.0 cm liver mass considered to be liver metastasis. She synchronously underwent right colectomy with D3 lymph node dissection and subsegmentectomy 8 under the diagnosis of advanced colon cancer with liver metastasis. The pathology examination revealed the liver nodule was pure squamous cell carcinoma (SCC), whereas histology of colon cancer was a well differentiated tubular adenocarcinoma containing no squamous component. The patient underwent intensive checkup by imaging for a primary site of SCC. However, no lesion considered as possible primary site of SCC was found. Therefore, the liver nodule was finally diagnosed as a primary hepatic SCC. Primary SCC of the liver is a rare and high-grade malignant tumor. Recurrent multiple liver nodule was found at 13 months after surgery and the patient died of cancer 17 months after surgery.